The home as a site for teaching gerontology and chronic illness

The care for the chronically ill elderly is a major national health problem. Considerable concern and attention have been focused on the shortcomings of medical education in this area of care. Research findings have demonstrated the relevance of a home care experience for teaching the interactions of the social, psychological, environmental, and biological factors which characterize chronic illness. The value of such an experience has taken on added significance in light of the federal government's prospective payment system for reimbursing health care costs under the Medicare program, a system that encourages early discharge of patients from the hospital. To manage these patients successfully, physicians need to understand and appreciate the influence of social, psychological, and environmental factors in the course of a disease. The home setting is an appropriate place for teaching about these factors, just as the hospital ward is appropriate for the understanding required of acute illness.     

Variations in length of stay and outcomes for six medical and surgical conditions in Massachusetts and California

OBJECTIVES.--To determine the extent to which interinstitutional variations in length of stay are explained by differences in patient characteristics and to determine whether patients in hospitals with shorter lengths of stay had worse outcomes. DESIGN.--We reviewed patients' medical records and surveyed patients between 3 and 12 months after hospital discharge using a questionnaire. SETTING.--Six teaching hospitals in California and Massachusetts. PATIENTS.--A cohort of 2484 selected patients who had been hospitalized for acute myocardial infarction or to rule out acute myocardial infarction, coronary artery bypass graft surgery, total hip replacement, cholecystectomy, or transurethral prostatectomy. Between 73% and 84% of the patients with each condition completed a follow-up questionnaire. OUTCOME MEASURES.--In-hospital complications, deaths, length of stay, functional status after hospital discharge, readmission, and patient satisfaction with hospital care were analyzed. RESULTS.--Significant interinstitutional differences in length of stay were noted for all conditions except rule-out acute myocardial infarction. Statistical adjustment for case-mix differences accounted for most of the interinstitutional differences in length of stay for total hip replacement but explained little of the differences in the other conditions. When we controlled statistically for other predictors, length of stay did not have a significant impact on deaths, functional status after hospital discharge, the probability of readmission, or patient satisfaction with hospital care. CONCLUSION.--More research is needed to determine the medical practices that are related to variations in lengths of stay. Routinely available outcome data may help preserve quality in the face of efforts to decrease costs by effecting more standardized practices of care.     

The need for acute, subacute, and nonacute care at 105 general hospital sites on Ontario

BACKGROUND: Previous studies of hospital utilization have not taken into account the use of acute care beds for subacute care. The authors determined the proportion of patients who required acute, subacute and nonacute care on admission and during their hospital stay in general hospitals in Ontario. From this analysis, they identified areas where the efficiency of care delivery might be improved. METHODS: Ninety-eight of 189 acute care hospitals in Ontario, at 105 sites, participated in a review that used explicit criteria for rating acuity developed by Inter-Qual Inc., Marlborough, Mass. The records of 13,242 patients who were discharged over a 9-month period in 1995 after hospital care for 1 of 8 high-volume, high-variability diagnoses or procedures were randomly selected for review. Patients were categorized on the basis of the level of care (acute, subacute or nonacute) they required on admission and during subsequent days of hospital care. RESULTS: Of all admissions, 62.2% were acute, 19.7% subacute and 18.1% nonacute. The patients most likely to require acute care on admission were those with acute myocardial infarction (96.2% of 1826 patients) or cerebrovascular accident (84.0% of 1596 patients) and those admitted for elective surgery on the day of their procedure (73.4% of 3993 patients). However, 41.1% of patients awaiting hip or knee replacement were admitted the day before surgery so did not require acute care on admission. The proportion of patients who required acute care on admission and during the subsequent hospital stay declined with age; the proportion of patients needing nonacute care did not vary with age. After admission, acute care was needed on 27.5% of subsequent days, subacute care on 40.2% and nonacute care on 32.3%. The need for acute care on admission was a predictor of need for acute care during subsequent hospital stay among patients with medical conditions. The proportion of patients requiring subacute care during the subsequent hospital stay increased with age, decreased with the number of inpatient beds in each hospital and was highest among patients with congestive heart failure, chronic obstructive pulmonary disease and pneumonia. INTERPRETATION: In 1995, inpatients requiring subacute care accounted for a substantial proportion of nonacute care days in Ontario's general hospitals. These findings suggest a need to evaluate the efficiencies that might be achieved by introducing a subacute category of care into the Canadian health care system. Generally, efforts are needed to reduce the proportion of admissions for nonacute care and of in-hospital days for other than acute care.     

优化护理管理策略在慢性阻塞性肺疾病患者的应用研究

目的 探讨优化护理管理策略在慢性阻塞性肺疾病(COPD)患者的护理效果.方法 将72例COPD患者随机分为实验组和对照组,其中对照组接受常规护理和治疗,实验组在常规治疗的基础上实施优化护理,包括系统化的健康宣教、心理护理、呼吸功能训练等护理措施.比较两组并发症的治愈率、住院时间和住院费用.结果 两组并发症治愈率、住院时间和住院费用差异均有统计学意义(P<0.05).结论 积极实施优化护理管理策略可促进COPD患者相关并发症的治愈、减少住院时间和住院费用,有利于患者康复.     

老年股骨颈骨折患者行人工髋关节置换围手术期临床护理路径的研究

目的 评价老年股骨颈骨折患者行人工髋关节置换围手术期临床护理路径的制定和应用效果.方法 96例单侧股骨颈骨折老年患者随机分为观察组和对照组各48例,观察组采用临床护理路径,对照组采用常规护理,对比两组髋关节恢复情况、生活质量、健康教育效果和满意度.结果 观察组出院当天、术后1个月Harris髋关节功能评分显著高于对照组(P均＜ 0.05).出院时两组SCL-90量表各因子评分差异均有统计学意义(P均＜0.05).观察组健康教育评分和护理满意度均显著高于对照组(P均＜0.05).两组并发症发生率比较差异有统计学意义(P＜0.05).结论 实施临床护理路径能保证老年股骨颈骨折患者在人工髋关节置换围手术期获得良好的医疗服务,提高髋关节功能恢复效果、生活质量、健康教育效果及护理满意度.     

延伸护理对人工全髋关节置换术后患者生活质量及髋关节功能恢复的影响

目的探讨延伸护理对人工全髋关节置换术后患者生活质量及髋关节功能恢复的影响。方法选取人工全髋关节置换术的患者共120例,按照住院号尾数单双号分为观察组和对照组各60例。观察组患者延伸护理指导,而对照组患者仅给予常规护理指导及出院后电话随访,采用Barthel指数评分及Harris髋关节评分对患者的日常生活能力以及髋关节功能恢复情况进行评价。结果术后3个月、6个月及1年后观察组患者的Barthel指数评分及Harris髋关节评分明显高于对照组,1年后观察组患者髋关节功能的优良率明显高于对照组（P〈0.01）。结论系统的延伸护理服务能够有效地提高人工全髋关节置换术患者的日常生活能力和促进髋关节功能的恢复,提高患者的生活质量。     

A cost-effectiveness analysis of hormone replacement therapy in the menopause.

OBJECTIVE: To evaluate the cost-effectiveness of hormone replacement therapy in the menopause with particular reference to osteoporotic fracture and myocardial infarction. DESIGN: The multiple-decrement form of the life table was the mathematical model used to follow women of age 50 through their lifetime under the "no hormone replacement" and "hormone replacement" assumptions. Standard demographic and health economic techniques were used to calculate the corresponding lifetime differences in direct health care costs (net costs in dollars) and health effects ("net effectiveness" in terms of life expectancy and quality, in "quality-adjusted life-years"). This was then expressed as a cost-effectiveness ratio or the cost ($) per quality-adjusted life-year (QALY) for each of the chosen hormone replacement regimens. SETTING AND PATIENTS: All women of age 50 in New South Wales, Australia (n = 27,021). RESULTS: The analysis showed that the lifetime net increments in direct medical care costs were largely contributed by hormone drug and consultation costs. Hormone replacement was associated with increased quality-adjusted life expectancy, a large percentage of which was attributed to a relief of menopausal symptoms. Cost-effectiveness ratios ranged from under 10,000 to over a million dollars per QALY. Factors associated with improved cost-effectiveness were prolonged treatment duration, the presence of menopausal symptoms, minimum progestogen side effects (in the case of oestrogen with progestogen regimens), oestrogen use after hysterectomy and the inclusion of cardiac benefits in addition to fracture prevention. CONCLUSIONS: Hormone replacement therapy for symptomatic women is cost-effective when factors that enhance its efficiency are considered. Short-term treatment of asymptomatic women for prevention of osteoporotic fractures and myocardial infarction is an inefficient use of health resources. Cost-effectiveness of hormone replacement in asymptomatic women is dependent on the magnitude of cardiac benefits associated with hormone use and the treatment duration.     

实施优质护理服务的效果评价

目的为了响应卫生部颁布的"优质护理服务示范工程"治疗号召,夯实基础护理。方法我院康复中心采用做好优质护理服务宣传、适当的环境改造、全面评估患者的护理需求,根据评估结果,为患者提供全程化、个性化、无缝隙的护理、为特殊患者提供出院评估和出院计划、加强健康教育、加强专科护理建设等方法,为患者提供优质护理服务。结果提高了患者满意度,缩短了患者住院天数,减少了患者的住院费用。结论做好优质护理服务,能让患者满意,医院满意,社会满意,提升护士的自身价值。     

髋关节置换术患者围术期护理

目的：总结有关全髋关节置换术围术期的护理经验,提高护理人员的技术水平。方法：对我院57例髋关节置换术患者围术期护理措施进行总结分析。围术期护理包括术前护理（术前健康评估、心理护理、术前适应性锻炼及术前常规准备）和术后护理（病情观察、基础护理、预防并发症、康复训练指导及出院后的注意事项、功能锻炼指导）两个方面。结果：57例患者全部安全度过围术期,未发生严重并发症,全部康复出院。结论：正确的康复护理是全髋关节置换术成功的重要环节,做好髋关节置换术围术期的整体护理,能有效减少并发症,减轻患者痛苦,是手术成功及提高患者的生活质量的关键。     

可伸缩护理支撑架在小儿泌尿外科术后护理中的应用效果

目的探讨可伸缩护理支撑架用于小儿泌尿外科患儿术后护理中的效果。方法本次研究选择小儿泌尿外科术后患儿80例,随机分为实验组和对照组,对照组采用常规的护理方法,实验组在对照组的基础上加用可伸缩的护理支撑架。结果实验组在每天换药次数、臀部红疹发生率、医疗护理费用上与对照组比较有显著差异性;在平均住院日上两组对比无显著差异性。结论可伸缩护理支撑架的应用,可降低小儿泌尿外科术后患儿的每日换药次数及住院总费用,降低术后患儿臀部红疹的发生率。常规护理方法加可伸缩护理支撑架应用于小儿泌尿外科患儿术后护理优于传统的护理方法。     

护理路径在全髋关节置换术患者健康教育中的应用

目的探讨护理路径在全髋关节置换术患者健康教育中的应用效果。方法将80例全髋关节置换患者随机分为观察组和对照组,每组各40例。对照组采用传统健康教育,观察组采用临床路径健康教育,即针对患者入院不同时间段(患者的入院,术前,术后和出院)制定标准化的健康教育内容,并按照健康教育护理路径流程实施健康教育,比较两组患者健康知识掌握情况、护理满意度及术后康复情况等。结果两组患者并发症的发生率、健康教育知识的达标率、患者对护理工作的满意率、住院时间及住院费用差异均有统计学意义(P<0.05)。结论应用临床路径对全髋关节患者实施健康教育,较传统健康教育方法更能使患者掌握健康知识,有利于减少并发症,提高护理质量。     

人工髋关节置换术的整体护理

目的 :研究整体护理对促进人工髋关节置换术患者康复的作用。方法 :对 186例人工全髋关节置换术患者实施术前、术后的整体护理 ,通过防褥疮、防感染及饮食护理等手段 ,以促进患者肢体功能早日恢复。结果 :通过整体护理 ,术后 2周拆线 ,患者可下地锻炼行走 ,无褥疮、假体脱位等并发症出现。结论 :系统的整体护理能够帮助该类患者早日康复 ,减少术后并发症的出现 ,明显提高患者的生活质量。     

记忆合金环抱器治疗髋关节置换术后股骨骨折

目的 探讨记忆合金环抱器治疗髋关节置换术后股骨骨折的方法及疗效。方法 采用记忆合金环抱器治疗髋关节置换术后股骨骨折7例，骨折均位于假体远端。结果 7例患者均获随访，所有患者均获骨性愈合，假体稳定，无X线松动表现，髋、膝关节功能恢复较好。结论 髋关节置换术后的股骨骨折采用记忆合金环抱器内固定，固定牢固，骨折愈合好，是一种值得推荐的方法。     

患者术后家庭延续护理模式研究

目的：探讨患者术后家庭延续护理模式,提高患者的生活质量,降低患者因住院带来的经济负担。方法100例患者术后3-4d出院,出院后视病情5-7d行家庭访视、伤口换药、拆线、健康指导等,对患者的健康行为、家庭护理需求、满意度等项目进行问卷调查。并行3-6月电话随访。结果切口 I期愈合率〈99%,伤口感染率为0;患者的住院费用降低25-30%;教育覆盖率达到100%;患者家属满意率〈95%;患者的健康行为形成率达到90%以上。结论术后患者家庭延续护理是医院工作的重要组成部分,降低了住院费用与医疗成本,促进了患者康复。     

Appropriateness in health care delivery: definitions, measurement and policy implications.

A major focus of the current health care debate is the notion that a substantial proportion of the health care delivered in Canada is inappropriate. There are two types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided (i.e., inpatient v. outpatient or home care). Measuring both types objectively requires the comparison of observed patterns of care with explicit criteria for appropriate care. The few studies of appropriateness conducted in Canada have shown that inappropriate services are provided and inappropriate settings are used. Reducing inappropriate health care delivery could involve active strategies for the implementation of guidelines and better cooperation and coordination within the health care system. However, lower rates of health care delivery or even inappropriate health care will not necessarily translate into higher quality care or lower costs overall.     

Hip fracture management: tailoring care for the older patient

Hip fracture is a potentially devastating condition for older adults. Hip fracture leads to pain and immobilization with complications ranging from delirium to functional loss and death. Although a mainstay of treatment is orthopedic repair, a multidisciplinary comanagement approach, including medical specialists and rehabilitation, may maximize patient recovery. Using the case of Mr W, an older man who sustained a fall and hip fracture, we present evidence-based components of care both in the hospital and outpatient settings. Preoperatively, clinicians should correct medical abnormalities and consider the appropriateness, timing, and type of surgical repair in the context of the patient's life expectancy and goals of care. Perioperative care should include prophylaxis with antibiotics, chemoprophylaxis for venous thromboembolism, and correction of major clinical abnormalities prior to surgery. Pain control, delirium, and pressure ulcer prevention are important inpatient care elements. Multidisciplinary models incorporating these care elements can decrease complications during inpatient stay. Rehabilitation strategies should be tailored to patient needs; early mobilization followed by rehabilitation exercises in institutional, home, and group settings should be considered to maximize restoration of locomotive abilities. Attention to care transitions is necessary and treatment for osteoporosis should be considered. The road to recovery for hip fracture patients is long and most patients may not regain their prefracture functional status. Understanding and anticipating issues that may arise in the older patient with hip fracture, while delivering evidence-based care components, is necessary to maximize patient recovery.     

Concerns about increasing use of ambulatory care raised at QMA annual meeting.

Quebec Health Minister Dr. Jean Rochon is pushing for a regionalized health care system that favours ambulatory care, day surgery and home care over hospital admissions and acute care in hospital. The Quebec Medical Association is concerned these changes will lower the quality of care in the province.     

全髋关节置换患者延续性护理需求的调查

目的调查全髋关节置换术后患者出院后对护理内容、方式的需求,作为患者出院后实施延续性护理的可靠依据。方法采用自制的全髋关节置换术后患者延续性护理调查表对122例患者在出院前1天进行调查,对调查结果进行统计分析。结果全髋关节置换术后患者对延续性护理需求超过80%的分别是禁忌动作内容、居家护理技巧、康复功能锻炼、血栓相关知识、缓解疼痛的方法,得分均在4.23分以上;患者对延续性护理方式需求超过60%的分别是微信平台、电话随访。结论全髋关节置换术后患者对延续性护理的需求内容和方式呈多样性,护士应针对患者的情况,制定有针对性、个体化的延续性护理服务和回访方式,促进患者肢体功能康复,减少并发症,减少住院次数,减轻患者与家属的经济负担。     

Assuring the quality of health care for older persons. An expert panel's priorities

To select topics for quality assurance activities focusing on older patients, we convened a 14-member panel of physicians and experts in quality assurance. In two rounds of ratings, panelists rated 42 medical conditions (eg, pneumonia) in terms of their effects on patient outcomes, the availability of beneficial interventions, and the health benefits from improving current quality. They rated 27 health services (eg, adult day-care) on similar dimensions. The feasibility of doing quality assurance work on each condition and service also was rated. Using the ratings, the conditions selected for quality assurance work were congestive heart failure, hypertension, pneumonia, breast cancer, adverse effects of drugs, incontinence, and depression. Health care services selected were hospital discharge planning, acute inpatient care for the frail elderly, long-term-care facilities (intermediate-care facilities and skilled nursing facilities), home health care services, and case management.     

家庭干预对老年慢性阻塞性肺疾病患者健康影响观察

目的:探讨家庭护理干预对老年慢性阻塞性肺疾病患者健康的影响。方法:100例符合条件的慢性阻塞性肺疾病患者作为研究对象,试验组和对照组各50例,试验组实施家庭干预,对照组进行常规健康宣教,对两组患者进行并发症发生率的评定。结果:随访1年后,试验组的并发症发生率明显低于对照组,差异有统计学意义。结论:实施家庭干预能有效降低老年慢性阻塞性肺疾病患者并发症的发生率,提高患者生活质量,降低病死率。